DSM

Saturday, 30 June 2007 10:49
Dr. Hazem El-Oraby

DSM stands for “Diagnostic and Statistical Manual of Mental Disorders” and is published by the American Psychiatric Association, the professional membership organization representing United States psychiatrists. It is utilized by mental health professionals from a variety of disciplines and backgrounds for a wide range of purposes, including clinical, research, administrative, and educational.

The DSM is a manual that contains a listing of psychiatric disorders and their corresponding diagnostic codes. Each disorder included in the manual is accompanied by a set of diagnostic criteria and text containing information about the disorder, such as associated features, prevalence, familial patterns, age-, culture- and gender-specific features, and differential diagnosis. No information about treatment or presumed etiology is included. Diagnostic criteria have been included in the DSM because their provision has been shown to increase diagnostic agreement. It is important to understand that the appropriate use of the diagnostic criteria requires clinical training and that they cannot be simply applied in a cookbook fashion. The primary purpose of the DSM is to facilitate communication among mental health professionals. The diagnostic terms in the manual provide a convenient shorthand when communicating about patients. For example, when a clinician making a referral uses the term “Major Depressive Disorder” to indicate the patient's diagnosis, he or she is communicating in three words a great deal of clinical information. One can expect that the patient's primary complaint is a sustained period of depressed mood or loss of interest in activities and that a number of other symptoms may occur as part of the depression, including sleep disturbances, changes in appetite or weight, low energy, difficulty concentrating, and very low self-esteem. The clinician should also be on the alert to look for suicidal ideas or plans because this feature is often present in patients with this diagnosis. Furthermore, use of the diagnostic term “Major Depressive Disorder” also indicates what NOT to expect. For example, using this term indicates the absence of significant manic periods now or in the past; otherwise, the clinician would have used the term Bipolar Disorder. Another important aspect of the DSM diagnostic system is that the diagnoses are described strictly in terms of patterns of symptoms that tend to cluster together; the symptoms can be observed by the clinician or reported by the patient or family members. Since the cause of most mental disorders is currently unknown and subject to much speculation, the DSM avoids incorporating unproven theories in its diagnostic definitions. This feature has been an important element in the widespread acceptance of the DSM. Clinicians from widely differing theoretical orientations can still use the DSM because it focuses on manifest symptoms. This is also an important limitation of the DSM system. Patients sharing the same diagnostic label do not necessarily have disturbances that share the same etiology nor would they necessarily respond to the same treatment. It is therefore critical to understand that the diagnostic terms and categories in the DSM represent only our current knowledge about how symptoms cluster together. We fully expect that, over the coming decades, the DSM system will be radically reorganized as the etiologies of mental disorders become better understood.

The current version of the DSM, called the DSM-IV-TR, was published in July 2000. This is considered to be a minor revision in that changes were, for the most part, confined to the descriptive text that accompanied each disorder. The most recent major revision was DSM-IV, published in 1994. In all, there have been 4 major revisions of the DSM. The first edition of the DSM was published in 1952. Subsequent revisions included DSM-II, (published in 1968), DSM-III (published in 1980), DSM-III-R (published in 1987), and DSM-IV (published in 1994).

The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the official coding system of the United States used to track morbidity and mortality of diseases. The system is maintained by the federal government. For more information about ICD-9-CM and to download a copy, click here. The ICD-9-CM codes are also used to code diagnoses for reimbursement of medical care. The DSM-IV-TR is a diagnostic manual that employs the ICD-9-CM codes to assist the clinician in medical record keeping. Because the DSM-IV-TR includes a number of subtypes that were added since ICD-9-CM was originally developed in the 1970's, most of the subtypes and specifiers included in DSM-IV-TR cannot be indicated through the diagnostic codes. Click here for more information about Diagnostic Coding and DSM-IV-TR.ICD-10, the tenth revision of the International Classification of Diseases, was published by the World Health Organization in 1993. Although DSM-IV and DSM-IV-TR were developed with the explicit goal of ICD-10 compatibility, they include ICD-9-CM codes since implementation of ICD-10 in the United States has been significantly delayed. Currently, the National Center for Health Statistics is developing a modification of ICD-10 for use in the United States to be known as ICD-10-CM that will be field-tested over the next several years. It is currently anticipated that it will be officially implemented in 2008. (For more information about ICD-10-CM, click here). Around that time, a DSM-IV Coding Revision (DSM-IV-CR) will be published which will include the ICD-10-CM codes in place of the ICD-9-CM codes.